| ADDRESS: 805 DEVELOPMENT DR, KINGSTON, ON K7M 4W6 TEL: 613-389-8660 EMAIL: reception@davidgouettdentistry.com
# PATIENT CONSENT FORM: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION (PIPEDA LEGISLATION) Official Clinical Data Record Submission
Privacy of personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients. In this office, Dr. David Gouett acts as the Privacy Information Officer. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. We have outlined what our office is doing to ensure that: Only necessary information is collected about you; We only share your information with your consent; Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols; Our privacy protocols comply with Privacy Legislation, Standards of our Regulatory Body, the Royal College of Dental Surgeons of Ontario, and the Law. Do not hesitate to discuss our policies with Dr. David Gouett or any member of our office staff. Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care. HOW OUR OFFICE COLLECTS, USES AND DISCLOSES PATIENTS PERSONAL INFORMATION Our office understands the importance of protecting information. To help you understand how we are doing that, we have outlined here how our office using and disclosing your information. The office will collect, use and disclose information about you for the following purposes: To deliver safe and efficient patient care To identify and to ensure continuous high quality service To assess your health needs and to provide health care To advise you of your treatment options To enable us to contact you To establish and maintain communication with you To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care To communicate with other health treating providers, including specialists and general Dentists who are the referring Dentists and/or peripheral Dentists To allow us to maintain communication and contact you to distribute healthcare information and to book and confirm appointments. This may include sending e-mail/text reminders to book and confirm appointments To allow us to efficiently follow-up for treatment, care and billing To complete/submit predeterminations and dental claims for third party adjudication and payment; to provide further information that your insurer may request to aid I the processing to predeterminations and claims To comply with legal and regulatory requirements, including the delivery of patients charts and records to The royal college of Dental Surgeons of Ontario in a timely fashion, when required and records to the provisions of the Regulated Health Professions Act To comply with the agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patients charts and records to the College in a timely fashion for regulatory monitoring purposes To permit potential purchasers, practise brokers or advisors to evaluate the dental practice To allow potential purchasers or practice brokers to conduct an audit in preparation for a practice sale To deliver invoices and to process credit card payments To collect unpaid accounts To assist this office in complying with all regulatory requirements To comply generally with the law By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Your information may be assessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense of a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of request is made, we will forward the information directly for your review, and for your specific consent. When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate. You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of the decision, and the process.
Patient Consent Submission
✓ | I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information.
✓ | I know that your office has a Privacy Code, and I can ask to see the Code at any time.
✓ | I agree that Dr. David Gouett Dentistry Professional Corporation can collect, use and disclose personal information about [Patient Name Response] as set out above in the information about the office's privacy policies.
Signature [Digitally Endorsed by Patient] |  | Print Name (Relationship to patient if signing for child) [Full Name Response]
Date [mm/dd/yyyy] |  | Signature of Witness [Digitally Endorsed by Witness]
© 2026 David Gouett Dentistry. This record is protected under PIPEDA and PHIPA legislation. Unauthorized disclosure of this clinical information is strictly prohibited.